HomeMy WebLinkAboutCLAUDE H SMITH LT 2
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
't ' ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
~~XX~X~XX KOEHLER CONSTRUCTION I ,4,"/~ E]UPGRADE
MAI LING ADDRESS ~'6
LEGAL DESCRIPTION
LOCATION NO. OF BEDROOMS
U~ DISTANCE TO: /~ / ~ Il/ ' ~/
~ Z Manufacturer Material No. of comp~rtments
Liq. capacity in gallons Inside length Width Liquid depth
/~ ~ IF HOME,DE: ~
_~ D~ST~NCETO: W~" D~e, ing ,ER~T,O.
~-- ~ Manufacturer Material Liquid capacity in gallons
O Well ~'~ Foundation ~ Nearest lot line ~/ PERMITNO.
Distance bet~en lin~s
~ ~~ No. of lines ~ Length of each~/line Total length~/~f lines_ Trench w '
~ ~ ~ Top ~f tile to finish ~rade , Material beneath tile Total effective absorptio~rea
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
Class Depth Driller Distance to lot line PERMIT NO.
· ~ ,.'~'~ ~ ~ . .............
~ Bud~mg ~undat~on ~ewer hne Septic tank Absorption area(s)
DISTANCE TO:
OTHER
PIPE MATERIALS
SOILT~STRATING I'~¢~ ~ ~'' '~~
)~
INSTALLER
REMARKS
APPROVED DATE LEGAL
72-013 (Rev. 3/78)
F
R
0
M
~T~i~o 4S 472
SIGNED
SEND PARTS 1 AND 3 WITH CARBON INTACT -
PART 3 WILL lie RIITURNRD WITH REPLY.
DATE
POLY PAK (50 SETS) 4P472
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological 8, Geophysical Surveys
Drilling Permit No.
LOCATION OF WELL (Please complete etther la, lb or lc.) A.D.L. No.
Meridian
,o.ljso.o.g. 'Su~d,.~.,on Lot B.oc. ~1 '/4.'''' S.c,,o..o. To-...'p.~a .e.g. ED
~J ~,o~.C~ ~.~ o,.~C~,O.7.o~ .0~ ,.~S~o~o.~ ~. ow.~. O~ ~; ....
2, WELL LOG Feet Belo~
Surface 4. WELL DEPTH: (final) ,5. DATE OF ~MPLET~
Moteriol Type TopBottom ~
Backfilling Grovel peek
,o. ~,~,,c ,~,, ~v~: ~ / .,. //
___ . . , ~ ~ Dote
EEC o. ov, o,
- Equipment used:
II. PU~PIN~ ~VEL b~lo~ Iont lurfoc~ ~ YI[LD
~, I~ ~ ~ 7 ft. after 3 hrs. pumping__g.p.m.
~[~ L-~- __ft. after __hrs. pumping . g.p.m.
12.GROUTING Well Grouted: ~ Ye~ ~ No
Materiel: ~ Neet Cement ~ Other:
13. PUMP: (If available) HP
Length of Drop Pipe ~ pacity ~g.p.m.
14. REMARKS:
16. WATER WELL CONTRACTOR'S CERTIFICATION:
15. Water Timperature __o ~ F ~ C
T~is wlll~os d~ille~er my jur~tion ond.t~s ~eporl ~lrue lo the best of my knowledge and belief;
Re~e~ eusi~ Name / Contract License ~mber, ~ t
-State DGGS, PINK-Driller, CANARY CustO
F:'IERM I 'T' NO:
[)ATE ISSUED:
11 ...... 184
APF'L I CANT:
ADDRIESS:
COhI'T'ACT F:'HONE:
L"I" ~
,-..0~_, JL.,=, ~ CONST.
% BOX '7'73294
EAGL. E RIVER, AK 99577
688"- 3.'760
LEGAL. r~='c:n~;,T~z,
LOT SIZE:
/\ V
M .... BEDROOMS:
r -r. E,~_L Cf...
L,.],.,='"' ~ ]'"" N, A
.I... N RANG E!:: 1. !Al
L. isted bel.:w ape the optic)ns available 'Lc.'. y.r.',Lt in design:Lng youp -z4e. p'L:i.c
system. Choose 'Lhe option that best f'its 'i/our' site.
DE:PTH 'TC] PIPE £,D, ,OM (FT,)
GRAVEL DEPTH (F"T.)
TOTAL. DEPTH (F'T.)
GRAVEl_ WIDTH (FT.)
GRAVEL L ....GTI-I (FT,,)
GRAVEL VOLUME (CU,YDS.)
TANI< SIZE (GALS)
SOIl_ RATING (SQ.FT. /BR)
4, (-).. ]. ,, r,,., .~..~.
0.5 3.5
4.5 4.5
17.0 5.0
34.0 41.0
21.5 30.4
1,000.0 '~'~' 1,000.0 '~"~
] '~5 125
· ~.-~ DEF'TH TO PIPE BOTTOIH .::: 2.0 FT. REQLJIRES ADDITIONAL GROUND COVER
'= I , S_ .. · '
· ~.~ DEPTH TO PIPE BOTTOM < -'_"]~.~ F'T. RE~U!RES ~N~MILATION
.~-~. DEPTH TO F'IPE BOTTOM < 4.0 FT. MAY F;'.EQUIRE A I_.IF"f' STATION
· .~'~ TANK MUST HAVE AT LE':AST TWO COMF'AR]'ME~NTS
I certify that:
1. I am familiap with the requirements for an-site sewers and wells as set
~opth by the Munic:ipality o~ Anclno~age (MOA) and the St_~te of Alaska.
2. I will :i. nsta].], t. lne system in accopdance wit. ln all MOA cade..~ and pegulat:i.c)n.~.~,
and in compliance with tlne design cr~ite~ia of' this per'mit...
3. I will adhere ta all MOA and State (3£ Alaska r~equirements £aP t!ne set bac'k
di?~tances £r'om any existing well, was'Lewater disp, osa! system o!% pub].ic
sewer'age sy'...:rLem on this op any adjac:ent or near'by
3 b ed r' oc)m?;
4. I understand tha'L this permit is valid for' a maximum ,:':,f
any e, nl.argemer'~t will {~equ:ipe .ar'~ additional per're:Lt.
]'HEN (1) AN ELEC'FRIN::A{ .... F'ERMIT AND ]tqSF'ECTION MUST BE OBT~]:NED~ <2) AS-BU!LTS
WILL. NOT BE APPROVED WITFIOtJT AN ELECTRICAL. 1.4~, I...L.,]I~.~I~ REF'ORT:
EL[<CTRICAI_ [40RK MUST BE DONE BY A LICENSED ELECTF~:IC]:AN
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
DATE PERFORMED:
LEGAL DESCRIPTION:
5
6
7
8
9
10
11
12
13
14
15
16
COMMENTS
SLOPE SITE PLAN
WAS GROUND WATER t
ENCOUNTERED? ~-~-~ .oI
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN FT AND FT
PERFORMED
CERTIFIED BY:
72-008 (6/79)
/,~ SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
[] PERCOLATION
TEST
PERFORMED fOR:
LEGAL DESCRIPTION: ZY ~ C/~,~ '.~,~'~'~"/', ~,~'"~'~:~"~"
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
'~E ~T Az~7~
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
COMMENTS
SLOPE
SITE PLAN
0
P
E
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE /~ u ~/~ (minutes/inch)
TEST RUN BETWEEN FT AND ~ FT
72-008 (6/79)
SOILS LOG
PERFORMED FOR:
LEGAL DE~
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
PERCOLATION
TEST
1
2
3
4
5
6
7
8
9
SLOPE SITE PLAN
lO
11
12
13
14
15
18
19
20
2225-E
,E 25,, [971
WAS CR0UND WATER
ENCOUNTER ED~ I ~ Y 0
P~
IF YES, AT WHAT /
DEPTH? ~'~ ~/~'
Gross Net Depth to Net
Reading Date Time Time Water ,Drop
PERCOLATION RATE
(minutes/inch)
TEST RUN BETWEEN FT AND ~ FT
COMMENTS
PERFORMED BY:
72-008 (6/79)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOl LS LOG
PERCOLATION
TEST
PERFORMED FOR: ,~'
LEGAL OESCR,.T,ON:
DATE PERFORMED:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
COMMENTS '~ ~
7"EST
SLOPE SITE PLAN
WAS GROUND WATER ~,)
ENCOUNTERED? t~ ~w~ SL
O
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN FT AND FT
PERFORMED BY: ~a~'~e~
CERTIFIED BY: ~-~ ·
72-008 (6/79)
MUNICIPALITY 0f ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P,O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
xt-CEIVt: ,
GENERAL INFORMATION
Complete legal description
Lot 2, Claud H. Smith S/D
Location (site address or directions) 18111 Birchtree Street
Property owner
Klm & Mike Grimes
688-3832
Day phone
Mailing address
Lending agency
Day phone
Mailing address
Agent Remax/Kathi Olmsted
i6600 Centerfield Drive, Suite 20i,
Address
Day phone 694-4200
Eagle River,.-AK 99577
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
XXX ,
Individual well
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-4)25 (Rev. 1,91) Front MOA #21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm $ & $ ENGINEERING Phone
17034 Eagle River Loop Road No. 204
Address Eaqle River, Alaska 99577 ~
Engineer's signature ,/) _//J ~. _._/'~'~--'~ Date
DHH$ SIGNATURE
/ App,'oved for bedrooms.
Disapproved.
Conditional approval for
bedrooms, with
the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-(~es(Rev. 1/91) Ba~c MC)A~Zl -
tCEiVtu
JUN 1999
Municipality of Anchorage
DEPARTMENt OF HEALTH & HUMA~ '~TI~I=~NCH~JEAGF
.... :I~IV]RC)NMENTAL $]~ALSERVVICES DIVISION
Enwronmental Services D~wmon
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Legal Description:
Health Authority Approval Checklist
L ~ ~_~ ~,.~,.ob~__ ~ S ~ t T'~- Parcel I.D.: O ~"/ - A :~ ,,~ - ¢ 7
A. WELL DATA
Well type ~I2A vA--r"~.- If A, B, or C, attach ADEC letter. ADEC water system number
Log present~)
Total depth
· Date completed
Cased to ~ ~ ~
FROM WELL LOG
Sanitary sealt~)/N) ~
Casing height (above ground)
Wires properly protected (~1) '~1
AT INSPECTION
Date of test ~ --~ -~J~ ~"-" '~--5 '~
Static water level /-'J I I .~-t
Well production ~d-r' ~ ~ ~JE./-J g.p.m.
g.p.m.
WATER SAMPLE RESULTS:
Coliform ~ Nitrate ~, 5'"' Other bacteria
Date of sample: "--~-'~ 5f -'~~) Collected by: .~5
B. SEPTIC/HOLDING TANK DATA
Foundation cleanout ~/N)
Date of pumping ~/'~2,'/~clcl
ABSORPTION FIELD DATA
Dat~ installed J\~ ~ ~
Date installed ~-'~'---'~{ Tank size ~ooO Number of Compartments '7~ Cleanouts ~)_~__
Depression (Y/~ >5 High water alarm (Y/N) ~.3 I.,~
Pumper -~. ·
Soil rating (g.p.d./fF or fF/bdrm) /'J~'"./~/Z-System type
Gravel thickness below pipe ~,5~' Total depth
,J
bedrooms
Length J,// "' Width
Effective absorption area 5~ ""~-'~Monitoring Tube present~N)~ Depression over field (Y~ __
Date of adequacy test ~"~ "~} Results (~Fail) ',~,4~'-" For '~
Fluid depth in absorption field before test (in.); '.~ /" Immediately after~4)
Fluid depth ~,3." (ins) Minutes later: '~,~o Absorption rate =
__ gal. water added (in.): ,~o ~'
.g.p.d.
If yes, give date 'J A
Peroxide treatment (past 12 months) (Y~
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
Size in gallons
"Pump on" level at*
"p um offE_~Je.v~'~
High water alarm level at* ~-~q3'-atum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot ~O~
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation ~' ~ Property line ~,o TM Absorption field
Water main/service line J 0 Surface water/drainage \ ~ c> Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
Surface water
Curtain drain
Building foundation
Water main/service line
Driveway, parking/vehicle storage area
Wells on adjacent lots t c,
F. ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal records
in conformance with MOA_ H,~A_guidelines in effect on this date.
Signature
Engineer's Name J~ (~/~ ~ .-~ 7'- ~* ~'e ~,~,~
Date
HAA Fee $ ,'~(~T")
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
MUNICIPALITY OF ANCHO~GE
MEMORANDUM
WATER WELL ADVISORY
HEALTH AUTHORITY APPROVAL NO. ~ O ~ ~
During a recent Health Authority Approval on-site inspection
and test of the potable water supply well on Lot ~
Block --- of C I~ Ho ~'i~ Subdivision, the well's
productivity was determined to be O, ~ gallons per minute.
The minimum well productivity required by this Department
(AMC 15.55) for a ~ bedroom residence is~o ~/~ gallons
per minute. Although the subject well currently exceeds this
minimum requirement, all parties concerned are advised that the
production capacity of the well may fluctuate. Restriction
of non-critical water uses such as washing cars and watering
lawns and gardens may be required.
This advisory must be attached to all copies Of the subject
Health Authority Approval.
ROBERT C. COWAN, RE.
ROBERT A. SHAFER, RE.
HEALTH AUTHORIIY
APPROVALS
SEWER & WATER
MAiN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING $1UDIES
AND REPORI$
WELL INSPECTION
& FLOWIEST
SITE PLANS
ROAD DESIGN
SOILTEST
PERCOLATION
1EST
STRUCTURAL &
MECI ~,NICAL
INSPECTIONS
ON SITE
WA~ lrEWATER
ENSPOSAL SYSTEM
DESIGN
WELL FLOW TEST DATA
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-121 !
CLIENT: ~'"~ ~ ~,
LEGAL DESCRIPTION:
WELL DEPTH: ' ~
DATE DRILLING COMPLETED:
CASING DEPTH:
*MISC. D/~TA:
CASING HEIGHT: ~,.v~ .¥ SANITARY SEAL:
WIRES IN CONDUIT: ~rp GRADING O.K.:
BACTERIA AND NITRATE SA LES COLLECTED (date): ~'---&
TEST DATA:
METER puMpING DEPTH TO .-
CLOCK READING RATE WATER REMARKS
TIME (GAL) (GPM) (FT)
Io'.~--- -- ~S" swl ~c~ ~,-~
t~',~ ~,~ ~7~
J~ i0 oR '7?
RESULTS: WELL CURRENTLY PRODUCES
TESTED BY: _~._~
GPM WITH A ~Z..' DRAWD6WN
FLOW RATE NOT GUARANTEED--SUBSEQUENT VARIATIONS CAN OCCUR.
17034 NORTH EAGLE RIVER lOOP . SUITE 204 . EAGLE RIVER, ALASKA 99,577
18:19 FROM-CTE ENVIRONklENTAL
CT&E Environmenlal Serv;ce$ Inc.
5615301
T-Z16 P.OZ/03 F-30Z
CT&E Ret.//
C~ien! Name
Project Name/t/
Clien~ Sample ID
Orcicr~cl By
?WSE~
992268001
S & S Engineering
L2 Claud H. Smith
L2 Claud H. Smsth
Driakiug Wa~er
0
S:eapie Remarks:
Client lOt
Printed Date/Time 05/97~99 ~4:15
Collecled Date/Time 05/24/99 10:00
Received Date/Time 05/24/99 15:00
T~chnical Director: Steph~n C, Ede
ResuLTs
ALLo~e~Le Prep An4Ly$i$
0
0.500 u
0.500
$N18 92ZZB 05/24/99 KAP
EPA $00.0 10 ma~ 05/24/99 05/24/99
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
GENERAL INFORMATION
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name ['/~g-'~ E c,,c./1 .-~ Telephone: Home ~, ES~-~,~ I Business
Applicant Address ~ ~, ~ ~ ~ / ~ ~- ~/~/~ ~ ~ ~'~
(c) Applicant is (check one): Lending Institution ~~builder ~; Buyer ~; Other ~ (explain);
(d) Lending Institution /~o~r..;.-~-/ ~- ~-~J~'> /l~oe_.a,,~.~ Telephone
Address
(e)
Real Estate Company and Agent
Address
Telephone
(f)
~'~the HAA to the following address:
Other
TYPE OF RESIDENCE
Single-Family ~MUlti-Family I-I
Number of Bedrooms
WATER SUPPLY
Individual Well [~' Community[] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite I~Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 (11/84)
'ENGINEERING FIRM PROVIDII~G INSPECTIONS, TESTS, FILE SEARCH, D~, ~'A AND INFORMATION ,-
As certified by my seal affixed hereto and as of the validation date shown below, i verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
S & S ENGINEERING
Name of Firm
5RB 196X
Address Fa~kGL~- kiVeR, AK ~/~
Date
Telephone
DHEP APPROVAL
App, roved for, /, '~
Approved X Disapproved
Terms of Conditional A~proval
bedrooms by -z~r'~~, ~'
'~~Date
Conditional
/2 -//-
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
72-025 (11/84)
Well Classification
Well Log Present ~N)
Total Depth ~"~' /
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit ~1~,
Separation Distances from Well:
To Septic/Holding Tank on Lot
. ~C~UNICIPALITY OF ANCHORAGE (M
_,~ I~C~ ~ ~-J_EALTH AUTHORITY APPROVAL (HAA)
~ ~ c-~u,-
-~ - ~ ~o~ CHECKLIST- FEBRUARY 1984
~C~~ O~ ~
~ ~; ~ ~ .n~ 2~-4720
Lega Description:
WELL DATA ~~
~ - ~ If A, B, C, D.E.C. Approved (Y/N)
Date Completed ~ - ~ - ~ ~ Yield
Cased to ~[ Depth of Grouting
To Nearest Edge of Absorption Field on Lot /oC~ r./,
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments
Pump Set At
Sanitary Seal on Casing ~3'N)
Depression Around Wellhead (Y/~
; On Adjoining Lots /
; On Adjoining Lots
~"/~ To Nearest Public Sewer
~ To Nearest Sewer Service Line on Lot ~.. 5"/-/'
.~ ,f--~ ~t,V~t~-~,r''a'c~ ;Date /2 -1
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (~fN) Air-tight Caps (~/N)
Depression over Tank (Y/~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N) ~
Separation Distances from Septic/Holding Tank:
//-5'-,~ Size /~c~ No. of Compartments ~--
Foundation Cleanout (~/N)
Date Last Pumped /~_ -~ - ,J.qG,
/'~//~ 'for '~
Temporary Holding Tank Permit (Y/N)
To Water-Supply Well
To Property Line
To Water Main/Service Line
Course /%*///Or
To Building Foundation ~ -~
I
To Disposal Field /!
To Stream, Pond, Lake, or Major Drainage
Comments
Page I of 2
72-026(11/84)
C, ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~ //- ,,5" '
Width of Field S '
Square Feet of Absorption Area
Depression over Field
Results of Last Adequacy Test
Separation Distance from Absorption Field:
TO Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
Type of System Design
Length of Field ~('
Depth of Field
Gravel Bed Thickness
Standpipes Present
Date of Last Adequacy
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments *'~SGPT'/C_~VS~r~ ~sTActc'~'~ II-$'c~Y
To Property Line "I,~D//
To Exis"~'"" A~ng or bandoned System on
· On Adjoining Lots ~' ~'I'('-
TO Cutbank (if present)
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes (Y/N)
Comments
** Check Permitted Bedroom Rating Against HAA Request **
S &s EING;II EI.:RN E lNG
SRB 196X
SignedEAGLE RIVER, AK ~]~5~'7' Date ~
Company
Receipt No.
Date of Payment
Amount: $
MOA No.
Page 2 of 2
72-026 (11/84)